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• • 60V9 <br /> ♦' C <br /> STATEOFCAUPORMA "; <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A a, 'e <br /> COMPLETE THIS FORM FOR EACH FAINLITYISITE `'l�1UnN'� <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CILITY NAME NAME OF OPERATOR <br /> ADDRESS NE EST CROSS STREET PARCEL A(OPTIONAL) <br /> w fZ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> r <br /> V/!g CA c! <br /> i01NDICATE 0 CORPORATION 0 INDIVIDUAL EJ PARTNERSHIP O LOCAL-AGENCY (]COUNTYAGENCV' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> -If owner of UST Is a public agency,complete the following:new W Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IFINDIAN #OFTANKSATSITE E.P.A. I.D.#fcp Anal) <br /> RESERVATION <br /> FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY : NAME(LAST.FIRST) PHONE#'WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> G /— <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NA E CARE OF ADDRESS INFORMATION <br /> MAIL(w'JOrR ASTREET ADDRESS ✓ boxiolnEkale INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> CORPORATION TNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NOAM�E� STATE, ZIP Coqg ONE INWITH AREA ODE <br /> ILII. TA lae, TION•(MUST BrEOM ETED) <br /> NApt <br /> CARE OF ADDRESS INFORMATION <br /> MAILIIJ�OR STREET ADDRESS ✓ box 0iMkaU INDIVIDUAL = LOCAL-AGENCY E71sTATEAGENCV <br /> %¢' Q ,eoX— �/� =CORPORATION = ARTNERS P COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME PHONE#WITH AREA CODE <br /> I . D OF EQUALIZATION AGE FEE ACCOUNT NUMBER-Call(91 22-9669—if questions arise. <br /> TY(TK) HQ 4 4-,-,__L I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ w bindkalo Q I SELF-INSURED 2 GUARANTEE 3 INSURANCE x SURETY BOND <br /> 5 LETTEROFCREDIT 6 ExEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checks . <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D II.[::] III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM E(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEJAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILTTV# <br /> EEV 14 <br /> LOCATION CODE-OPTIONAL CE SDUSTRA�T# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTpNAL <br /> --r <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A("3) /T / 1 t), F,ORDIaMA7 <br /> • Ill lL'/Il IV{I'/ <br />